HomeMy Public PortalAbout5827 ALESSANDRO AVE_Mechanical__ DECLARAT
WORKER'S COMPENSATION
ate of consent to 76A346DPW9,69 APPLICATION FOR PERMIT LIME GREEN
hereby affirm that I'have a certificate of consent to self insure, 76A364C
or a certificate of;Worker's Compensation Insurance, or a certified HEATING=VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
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cy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified copy is filed with the county buildinginspection FOR APPLICANT TO FILL IN BUILDING C OZ (���{�D17 d
department. p (PRINT OR TYPE ONLY) ADDRESS r YC Al r
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Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE KIPAPPQT
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CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. L (N/IAS _Pk,
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR P ] r1
(This section need not be completed if the work involved by the MAP BOOK '5J)
5 UI/ PAGE 002 PARCEL00
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU G
become subject to the Workers' Compensation Laws. d
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL �,
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL ✓
Professions Code, and my license is in full force and effect.
License Number Lic.Class
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0..
Contractor Date 0
EJI am exempt under Sec. Plan Check fee
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B.&P.C.for this reason PERMIT ISSUING FEE$ 0
Date: TOTAL FEE �p d
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CDZ
I hereby affirm that I am exempt from the Contractor's License Law NAME '
for the following reason (Section 7031.5, Business and Professions
.Code): ADDRESS
❑ I, as owner of the property, or my employees with wages if_:ti, rY
as their sole,compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, 3
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Business and Professions Code). WNER L/AA10T �C,
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I, as owner of the property, am exclusively contractingpMAIL Z
with licensed-contractors to construct the project (Sec- ADDRESS S'O AITWA PRD 4F , !!ij-SL 7 ® CIO
tion 7044, Business and Professions Code). p� p f �� _fi'i
CONSTRUCTION LENDING AGENCY CITY `T GlT C1, TEL.NO.O l�Z1��2�3' e_11,-f,ECUK ?r; _,.:
I hereby affirm that there is a construction lending agency for CONTRACTOR G ✓I , (�-j ii = "?
the performance of the work for which this permit Is issued '
(Sec. 3097,Civ. C.).
ADDRESS
Lender's Name 1
CITY TEL.NO.
Lender's Address STATE LIC. +'-1y' i AN 41 3
I certify that I have read this application and state that the above LICENSE NO. CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
propert tion pur ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
G RE OF APP AGENT DATE